Go Back

CDPHP Value Rx (HMO)

H3388 - 004 - 0

(4.5 / 5)

CDPHP Value Rx (HMO) is a Medicare Advantage Plan by CDPHP Medicare Advantage.

This page features plan details for 2025 CDPHP Value Rx (HMO) H3388 – 004 – 0 available in Greater Capital Region of New York State.

Locations

CDPHP Value Rx (HMO) is offered in the following locations.

Albany County, New York

Broome County, New York

Chenango County, New York

Click to see more locations

Plan Overview

CDPHP Value Rx (HMO) offers the following coverage and cost-sharing.

Insurer:	CDPHP Medicare Advantage
Health Plan Deductible:	$0
MOOP:	$6,400 In-network
Drugs Covered:	Yes

Ready to sign up for CDPHP Value Rx (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

CDPHP Value Rx (HMO) has a monthly premium of $62.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$62.00	$	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

CDPHP Value Rx (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$62.00	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$5.00 Copay		$5.00 Copay
2) Generic		$18.00 Copay		$18.00 Copay
3) Preferred Brand	$42.00 Copay	$47.00 Copay	$42.00 Copay	$47.00 Copay
4) Non-Preferred Drug	39.00% Coinsurance	39.00% Coinsurance	39.00% Coinsurance	39.00% Coinsurance
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$10.00 Copay		$10.00 Copay
2) Generic		$36.00 Copay		$36.00 Copay
3) Preferred Brand	$84.00 Copay	$94.00 Copay	$84.00 Copay	$94.00 Copay
4) Non-Preferred Drug	39.00% Coinsurance	39.00% Coinsurance	39.00% Coinsurance	39.00% Coinsurance
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$15.00 Copay		$15.00 Copay
2) Generic		$54.00 Copay		$54.00 Copay
3) Preferred Brand	$126.00 Copay	$141.00 Copay	$84.00 Copay	$141.00 Copay
4) Non-Preferred Drug	39.00% Coinsurance	39.00% Coinsurance	39.00% Coinsurance	39.00% Coinsurance
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

CDPHP Value Rx (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Adjunctive General Services
- In-Network: No Coins – No Co pay (Limits Apply)
Endodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Implant Services
- In-Network: No Coins – No Co pay (Limits Apply)
Maxillofacial Prosthetics
- In-Network: No Coins – No Co pay (Limits Apply)
Oral and Maxillofacial Surgery
- In-Network: No Coins – No Co pay (Limits Apply)
Orthodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Periodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Prosthodontics, fixed
- In-Network: No Coins – No Co pay (Limits Apply)
Prosthodontics, removable
- In-Network: No Coins – No Co pay (Limits Apply)
Restorative Services
- In-Network: No Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay (Limits Apply)
Fluoride Treatment
- In-Network: No Coins – No Copay (Limits Apply)
Oral Exams
- In-Network: No Coins – No Copay (Limits Apply)
Other Diagnostic Dental Services
- In-Network: No Coins – No Copay (Limits Apply)
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

Outpatient x-rays
- $5 copay (Authorization Required, Referral Required)
Diagnostic tests and procedures
- $0-30 copay (Authorization Required, Referral Required)
Lab services
- $0-5 copay (Authorization Required, Referral Required)
Diagnostic radiology services (e.g., MRI)
- $130 copay (Authorization Required, Referral Required)

Doctor visits

Primary
- $0 copay
Specialist
- $0-30 copay per visit (Authorization Required, Referral Required)

Emergency care/Urgent care

Urgent care
- $55 copay per visit (always covered)
Emergency
- $110 copay per visit (always covered)

Foot care (podiatry services)

Routine foot care
- Not covered
Foot exams and treatment
- $30 copay (Referral Required)

Ground ambulance

- $225 copay

Health plan deductible

- $0

Hearing

Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- $30 copay
Fitting/evaluation
- $0 copay
Hearing aids
- $599-899 copay (Limits Apply)

Inpatient hospital coverage

- $295 per day for days 1 through 6
  $0 per day for days 7 through 90 (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $6,400 In-network

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)
- 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item (Authorization Required)
Diabetes supplies
- $10 copay or 0-20% coinsurance per item (Authorization Required)

Medicare Part B drugs

Other Part B drugs
- $35 copay or 0-20% coinsurance (Authorization Required)
Chemotherapy
- 0-20% coinsurance (Authorization Required)

Mental health services

Outpatient group therapy visit with a psychiatrist
- $30 copay (Referral Required)
Outpatient group therapy visit
- $30 copay (Referral Required)
Outpatient individual therapy visit with a psychiatrist
- $30 copay (Referral Required)
Inpatient hospital – psychiatric
- $275 per day for days 1 through 6
  $0 per day for days 7 through 90 (Referral Required)
Outpatient individual therapy visit
- $30 copay (Referral Required)

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $300 copay per visit (Authorization Required, Referral Required)

Preventive care

- $0 copay (Authorization Required)

Rehabilitation services

Physical therapy and speech and language therapy visit
- $30 copay (Referral Required)
Occupational therapy visit
- $30 copay (Referral Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $140 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

- $0 copay (Authorization Required)

Vision

Eyeglass lenses
- $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Routine eye exam
- $20 copay (Limits Apply)
Upgrades
- Not covered
Contact lenses
- $0 copay (Limits Apply)
Eyeglass frames
- $0 copay (Limits Apply)
Other
- Not covered

Wellness programs (e.g., fitness, nursing hotline)

- Covered